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General NPI Number Information
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NPI Number | 1740214402
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Entity Type | Organization
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Legal Business Name | COAST TO COAST MEDICAL, LLC
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Dates
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Enumeration Date | 07/10/2006
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Last Update Date | 12/02/2008
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Provider Practice Location Address
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Address Line | 2201 HORIZON DRIVE SUITE 4
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City | WEST MEMPHIS
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State | AR
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Zip | 72301
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Country | US
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Telephone | 870-732-0332
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Fax | 870-732-3078
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Provider Business Mailing Address
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Address Line | 2201 HORIZON DRIVE SUITE 4
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City | WEST MEMPHIS
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State | AR
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Zip | 72301
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Country | US
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Telephone | 870-732-0332
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Fax | 870-732-3078
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Authorized Official
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Title or Position | PROVIDER
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Name | DEBRA J SHIVERS
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Credential | ARNP
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Telephone | 870-732-0332
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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